Metabolic Assessment Form Name: Age: Sex: Date: PART I Please list the 5 major health concerns in your order of importance:... 4. 5. PART II Please circle the appropriate number - on all questions below. as the least/never to as the most/always. Category I Feeling that bowels do not empty completely Lower abdominal pain relief by passing stool or gas Alternating constipation and diarrhea Diarrhea Constipation Hard, dry, or small stool Coated tongue of fuzzy debris on tongue Pass large amount of foul smelling gas More than bowel movements daily use laxatives frequently Category II Excessive belching, burping, or bloating Gas immediately following a meal Offensive breath Difficult bowel movements Sense of fullness during and after meals Difficulty digesting fruits and vegetables; undigested foods found in stools Category III Stomach pain, burning, or aching - 4 hours after eating Do you frequently use antacids? Feeling hungry an hour or two after eating Heartburn when lying down or bending forward Temporary relief from antacids, food, milk, carbonated beverages Digestive problems subside with rest and relaxation Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine Category IV Roughage and fiber cause constipation Indigestion and fullness lasts -4 hours after eating Pain, tenderness, soreness on left side under rib cage Excessive passage of gas Nausea and/or vomiting Stool undigested, foul smelling, mucous-like, greasy, or poorly formed Frequent urination Increased thirst and appetite Difficulty losing weight Category V Greasy or high fat foods cause distress Lower bowel gas and or bloating several hours after eating Bitter metallic taste in mouth, especially in the morning Unexplained itchy skin Yellowish cast to eyes Stool color alternates from clay colored to normal brown Reddened skin, especially palms Dry or flaky skin and/or hair History of gallbladder attacks or stones Have you had your gallbladder removed Yes No Category VI Crave sweets during the day Irritable if meals are missed Depend on coffee to keep yourself going or started Get lightheaded if meals are missed Eating relieves fatigue Feel shaky, jittery, tremors Agitated, easily upset, nervous Poor memory, forgetful Blurred vision Category VII Fatigue after meals Crave sweets during the day Eating sweets does not relieve cravings for sugar Must have sweets after meals Waist girth is equal or larger than hip girth Frequent urination Increased thirst & appetite Difficulty losing weight Category VIII Cannot stay asleep Crave salt Slow starter in the morning Afternoon fatigue Dizziness when standing up quickly Afternoon headaches Headaches with exertion or stress Weak nails Symptom groups listed in this flyer are not intended to be used as a diagnosis of any disease condition. For nutritional purposes only. All Rights Reserved. Copyright 8, Datis Kharrazian SMGEMAF4(48).DOC
] Category IX Cannot fall asleep Perspire easily Under high amounts of stress Weight gain when under stress Wake up tired even after 6 or more hours of sleep Excessive perspiration or perspiration with little or no activity Category X Tired, sluggish Feel cold hands, feet, all over Require excessive amounts of sleep to function properly Increase in weight gain even with low-calorie diet Gain weight easily Difficult, infrequent bowel movements Depression, lack of motivation Morning headaches that wear off as the day progresses Outer third of eyebrow thins Thinning of hair on scalp, face or genitals or excessive falling hair Dryness of skin and/or scalp Mental sluggishness Category XI Heart palpations Inward trembling Increased pulse even at rest Nervous and emotional Insomnia Night sweats Difficulty gaining weight Category XII Diminished sex drive Menstrual disorders or lack of menstruation Increased ability to eat sugars without symptoms Category XIII Increased sex drive Tolerance to sugars reduced Splitting type headaches PART III Category XIV Urination difficulty or dribbling Urination frequent Pain inside of legs or heels Feeling of incomplete bowel evacuation Leg nervousness at night Category XV Decrease in libido Decrease in spontaneous morning erections Decrease in fullness of erections Difficulty in maintain morning erections Spells of mental fatigue Inability to concentrate Episodes of depression Muscle soreness Decrease in physical stamina Unexplained weight gain Increase in fat distribution around chest and hips Sweating attacks More emotional than in the past Category XVI Are you perimenopausal Yes No Alternating menstrual cycle lengths Yes No Extended menstrual cycle, greater than days Yes No Shortened menses, less than every 4 days Yes No Pain and cramping during periods Scanty blood flow Heavy blood flow Breast pain and swelling during menses Pelvic pain during menses Irritable and depressed during menses Acne break outs Facial hair growth Hair loss/thinning Category XVII How many years have you been menopausal? Since menopause, do you ever have uterine bleeding? Yes No Hot flashes Mental fogginess Disinterest in sex Mood swings Depression Painful intercourse Shrinking breasts Facial hair growth Acne Increased vaginal pain, dryness or itching How many alcohol beverages do you consume per week? How many caffeinated beverages do you consume per day? How many times do you eat out per week? How many times a week do you eat fish? List the three worst foods you eat during the average week:, List the three healthiest foods you eat during the average week:, Do you smoke? If yes, how many times a day: Rate your stress levels on a scale of - during the average week: Please list any medications you currently take and for what conditions: How many times a week do you eat raw nuts or seeds? How many times a week do you workout?,, Please list any natural supplements you currently take and for what conditions: All Rights Reserved. Copyright 8, Datis Kharrazian SMGEMAF4(48).DOC
No-show, Cancellation and, Late Policies There is one treatment room so that all of the attention during your appointment time is given to your care. Please be on time for your appointment. If you are going to be late, please text or call. More than minutes of lateness is equivalent to a no-show. If you need to cancel, please do so within 4 hours of your appointment. Otherwise, the appointment is equivalent to a no-show. If you don t show up for your appointment without making contact and for non-emergency reasons, such as your day got busy, you forgot, etc, then penalties can be applied as follows: First no-show no penalty as a show of good faith that it will not happen again. Second no-show - $ fee payable before your next appointment is scheduled. Third no-show - $6 fee payable before your next appointment is scheduled. Penalties can be avoided by rescheduling and showing up for your appointment the same calendar week. By signing below, I understand that less than 4 hours notice of cancellation, lateness, and not showing up for an appointment can result in penalties. Print name Signature Date Office signature Date
Electronic Contact Consent I agree to allow Krista J Essler, LAc and Acupuncture and Holistic Care for Wellness and Pain Management to contact me via the following e-mail address and mobile number (both voice and text messaging) for the purpose of appointment reminders, general practice updates, and to answer specific questions regarding my treatment. Further, contact can be made for the purpose of invoicing and billing and may contain specific treatment information. e-mail mobile number name signature date